Postmenopausal Vaginal Bleeding Research Articles

Ovarian Steroid Cell Tumor: Report Of Four Cases

SUMMARY Steroid cell tumors are tumors that account for less than 0.1% of all ovarian malignant tumors and cause increase in secretion of androgen or estrogen. Steroid cell tumors usually occur in the post-menopausal period. This article reports four steroid cell tumor cases who underwent surgery for overian mass during post-menopausal period, who were diagnosed with steroid cell tumor after histopathological examination and displayed different clinical manifestations. No signs of increased hormonal activity in two of these cases were On the other hand, the other two cases applied with complaints of menopausal vaginal bleeding, which led to the consideration of increased estrogenic activity in these two cases. Case 1 The case, who was 77 years of age in her postmenopausal period, applied to our hospital with the complaint of urinary incontinence. The routine laboratory findings of the patient, who had no feature in her history, were within normal limits. No findings of virilization were observed during the physical examination of the patient. During the gynaecological examination, a mass of approximately 6 cm was detected in the right adnexal area. The transvaginal ultrasonography (TVUSG) revealed an endometrial thickness of 9 mm, and an approximately 72mm-sized solid-cystic mass, surrounded with free liquid in the right ovary area. The preoperative Case 2 In the TVUSG performed during the routine follow- up examinations at the menopause clinic of the 52 year-old case, who did not have active complaints, a 66 X 35 mm mass with the possibility of dermoid cyst was detected in the right ovary. There was no feature in the patient's physical examination, her history and family history. The gynaecological examination, during which an approximately 6 cm mass was palpated in the right adnexial area, revealed a CA 125 value of 9.07 IU/ml. With the preliminary diagnosis of pelvic mass, laparoscopic right salpingo-ooforectomy was performed. The intraoperative pathological examination reported was not observed. The paraffin block indicated a right ovarian steroid cell tumor; the largest diameter of the capsule was 8 cm and the capsule had a ruptured appearance; there was 1 mitosis /10 HPF, focal light atypia and focal hemorrhage but there was no presence of necrosis. Based on these findings, it was decided that the potential for malignancy was low. Adjuvant treatment during the postoperative period was not considered. The patient did not come to the follow-up examinations after the operation. Figure 2: The postoperative paraffin block section of case 1. Case 3 The 64-year-old case who was in her postmenopausal period applied to our hospital with vaginal bleeding complaints. The routine laboratory findings of the patient, who had no feature in her history and family history, were within normal limits. In the physical examination of the case, virilization and increased hormonal activity findings were not It was thought that postmenopausal vaginal bleeding could be associated with hyperestrogenic environment. A 10 cm-diameter mobile mass, the borders of which could not be clearly differentiated from the uterus and right ovary and filled up the Douglas space, was detected during the gynaecological examination. The TVUSG

Carcinosarcoma of the corpus uteri (Malignant Müllerian Mixed Tumor): a case report in Yaoundé (Cameroon).

Carcinosarcoma of the uterus is a rare tumor representing 2-4% of uterine malignancies. Its prognosis is poor with a 5 years survival rate of 10-30%. We report a first documented case of carcinosarcoma occurring in a 62 years old woman who presented with postmenopausal vaginal bleeding for one year. The preoperative biopsy of endometrium revealed a leiomyosarcoma. Total body Computerized Tomography (CT) Scan revealed a mass limited to the uterus without other abnormalities. We carried out a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Post operative histology of the specimen found a carcinosarcoma. The patient underwent a course of radiotherapy and a total body CT Scan done eight months later revealed no signs of recurrence or metastasis. Clinicopathological aspects, treatment options and prognosis of this aggressive neoplasm are reviewed. We recommend practitioners to be aware of this lesion for an early diagnosis and appropriate treatment.

A Rare Case of Postmenopausal Bleeding: Choriocarcinoma

Choriocarcinoma is an aggressive malignant tumor comprised of sheets of anaplastic cytotrophoblast/syncytiotrophoblast cells. The majority of choriocarcinoma cases are of intra-uterine, gestational origin and generally develops within the first year following pregnancy, consequently it is generally observed within reproductive age groups. A 58-year-old woman was presented to our clinic with vaginal bleeding in the preceding months. The serum B-HCG level was 12414 mIU/mL. A pelvic ultrasound showed a 41 × 37 mm heterogeneous mass on the right anterior fundal wall of the corpus uteri, to which blood flow was increased on colour Doppler examination. Here in study, we present a case of postmenopausal uterine choriocarcinoma. Practitioner must be awareness of choriocarcinoma as a cause of postmenopausal vaginal bleeding. doi: http://dx.doi.org/10.4021/jcgo19w

Superficial spreading squamous cell carcinoma of the uterine cervix involving the endometrium: Report of two cases with emphasis on the likely molecular mechanism

Squamous cell carcinoma (SCC) of the cervix generally invades directly into the uterine wall, but in rare cases it spreads superficially to the inner surface of the uterus, thereby replacing the endometrium. This type is called superficial spreading SCC. In the present study we report two cases of this unusual form of cervical SCC and discuss the possible molecular mechanism involved. Two females, aged 64 (case 1) and 59 (case 2) years old, presented with post-menopausal vaginal bleeding. Histopathological studies of the resected specimens revealed non-keratinizing SCC of the cervix (pTIIA1 in case 1 and pTIIB in case 2). A notable finding in the two tumors was that atypical squamous cells were extending and replacing the endometrium directly from the cervix. Glandular involvement of atrophic endometrial glands was observed, however no invasive growth was observed in the endometrium in either case. Immunohistochemical studies revealed that CD138 was strongly expressed in the carcinoma cells superficially spreading in the endometrium in the two cases. It has been reported that the loss of expression of CD138, a cell-surface heparan sulfate proteoglycan participating in cell-cell and cell-extracellular matrix interactions, is correlated with tumor invasion and progression to cervical SCC. Our present findings suggest that CD138 expression in carcinoma cells may participate in superficial spread by regulating cell-cell interactions.

Association Between Uterine Prolapse and Cervical Squamous Cell Carcinoma in an Elderly Adult

To the Editor: A 77-year-old woman with a past history of five pregnancies, five births, and cardiac arrhythmias with atrial fibrillation was admitted through the gynecology clinic with a chief complaint of postmenopausal vaginal bleeding for 1 month. She had not ever undergone a Papanicolaou test. On physical examination, the gynecologist found complete prolapse of her uterus and a large mass (~6 × 6 cm) arising from the posterior uterine cervix and extending to the posterior vagina. The cervical mass was biopsied, and pathology revealed squamous cell carcinoma. She had anemia (hemoglobin 9.2 g/dL). Magnetic resonance imaging (MRI) of the pelvis (Figure 1A, B) and magnetic resonance urography (MRU) of the abdomen (Figure 1C) revealed a large lobular mass at the posterior cervix of the completely prolapsed uterus, cystorectocele, mild right hydroureteronephrosis, and moderate chronic left obstructive uropathy with moderate left hydroureteronephrosis. A regional lymphadenopathy was also noted at the left side of the pelvis. The clinical staging statuses of the cervical cancer were International Federation of Gynaecology and Obstetrics Stage IIB and cT2bN1M0 (T, primary tumor; N, regional lymph node; M, metastasis). She underwent total excision of the cervical cancer. The final pathological diagnosis was condylomatous squamous cell carcinoma of the uterine cervix with pathological staging status pT1b2. Postoperative tomoradiotherapy (intensity-modulated radiation therapy) was then undertaken with a delivery dose of 6,000 cGy in 30 fractions to the pelvis. In follow-up, the gynecologist managed her uterine prolapse using a pessary. Pelvic organ prolapse (POP), the descent of one or more female pelvic organs or compartments, mainly including the urinary bladder, uterus, and vagina, occurs more commonly in older women than younger.1-4 Development of POP is multifactorial as the result of failure of the support maintained by interaction of the levator ani muscles (pelvic floor muscles), the vagina, and the connective tissues and stretching injury of the pudendal nerve causing loss of the normal muscle tone of levator ani during vaginal delivery.1, 4 Vaginal childbirth, older age, higher body mass index, menopause, and low socioeconomic status are the generally accepted risk factors for POP.1, 2, 4 Other risk or predisposing factors include ethnicity (e.g., Hispanic), high intra-abdominal pressure (chronic cough, chronic lung disease, straining with chronic constipation, repeated heavy lifting), obstetric history (current pregnancy, previous prolonged labor, instrumental delivery, episiotomy, increased parity, birth weight), and previous surgery (hysterectomy, previous prolapse surgery).2, 4 Baden-Walker (Grades 0–4) and pelvic organ prolapse quantification (Stages 0–IV) are the two main systems for staging the severity of POP.2, 4 The former is a simple clinical method, whereas the latter is a complicated quantitative method that is highly reliable and involves several measurements.4, 5 Some studies have shown a linear association between uterine prolapse and age and a positive association between cystocele and rectocele and age up to sixth decade and then negative association with older age.3 The coincidence of uterine prolapse and cervical cancer is uncommon and usually happens in underdeveloped countries and in older women, although uterine prolapse and cervical cancer are not rare.6-8 The assumption that displacement of the uterine cervix from the natural environment of the vagina may decrease the neoplastic process of viral infection explains the lower risk of cervical cancer in uterine prolapse,6, 7 although the continual injury of the cervical epithelium may cause neoplasm.7 MRI along with MRU is a necessary noninvasive, nonionizing technique in evaluation of uterine prolapse associated with cervical cancer. Radiographic assessment is unnecessary for simple POP.2 The best treatment for cervical cancer associated with complete uterine prolapse has not been determined. The standard curative principle of cervical cancer, including radical surgery plus adjuvant radiotherapy or radical radiotherapy for early stages and chemoradiotherapy for locally advanced cancers is probably applicable to cervical cancer associated with uterine prolapse,6, 7 but urethral obstruction and silent upper urinary tract obstruction often complicate genital prolapse.9 MRI with multiplanar images is useful for preoperative evaluation of the pelvic regional lymph nodes for tumor staging and silent upper urinary tract obstruction level for treatment planning of POP to avoid surgical complications.9 Uterine prolapse is usually associated with cystocele and rectocele. Tomoradiotherapy is better than conventional radiotherapy in lowering radiation toxicity at the urinary bladder and the rectum.10 The options of treatment for symptomatic POP include observation, pessary, and surgery.2, 4 Pessary use should be considered before surgery in symptomatic women.4 The surgical strategies for POP include reconstructive and obliterative techniques.2 Conflict of Interest: None. Author Contributions: Concept and design: Wing-Keung Cheung and Szu-Fen Huang. Acquisition of participants and data: Wing-Keung Cheung, Min-Po Ho. Analysis and interpretation of data: Wing-Keung Cheung, Min-Po Ho, Ming-Chow Wei, Pei-Wei Shueng, Szu-Fen Huang. Preparation of manuscript: Wing-Keung Cheung. Critical review and approval: All authors. Sponsor's Role: None.

Eight cases of malignant mixed müllerian tumor (carcinosarcoma) of the uterus: Findings in surepath™ cervical cytology

Malignant mixed Müllerian tumor (MMMT)/carcinosarcoma is a rare neoplasm of the female genital tract characterized by a mixture of epithelial and mesenchymal components. There are published reports of conventional cervical smear findings in uterine MMMT, but to the best of our knowledge the cytomorphology of MMMT in SurePath™ liquid-based cytology samples has not been described. We present a series of eight cases of uterine MMMT in SurePath™ cervical samples. The mean age of the women was 65.5 years (range, 60-82 years) and the most common presenting symptom was postmenopausal bleeding. Three out of the eight cases had both epithelial and sarcomatous elements in highly cellular cervical samples. In two cases, abnormal glandular cell clusters were closely associated with the mesenchymal component. The glandular component was usually represented by three-dimensional clusters of malignant glandular cells and a dispersed population of large, round to oval malignant epithelial cells with single prominent nucleoli. Necrosis or tumor diathesis was not seen in any cases. Six out of the eight cases were initially reported as adenocarcinoma, endometrial type, and two cases as normal. Five cases had an atrophic background and tiny atypical glandular clusters that could easily be overlooked. Although cervical sample is not the method of choice for primary uterine carcinosarcoma screening, the possibility of the same should be kept in mind, when reporting a cervical sample from a woman with postmenopausal vaginal bleeding.

Management of postmenopausal women with vaginal bleeding when the endometrium can not be visualized

To determine the risk of endometrial cancer when endometrial thickness is not visualized using ultrasonography. Cross-sectional study. Gynecological oncology center in the United Kingdom. All postmenopausal women referred with vaginal bleeding. All women were investigated using gray-scale transvaginal ultrasonography. Women were arbitrarily stratified into four groups according to the endometrial thickness measurement. Women with endometrial thickness that was not adequately visualized on ultrasonography were included in a separate group. Endometrial cancer diagnosis. Over a 50-month period, 4454 women were investigated for postmenopausal vaginal bleeding. A total of 259 (6%) of women were diagnosed with endometrial carcinoma. Endometrial thickness measured 5-9.9 mm in 1201 (27%), 10-14.9 mm in 468 (11%), 15-19.9 mm in 209 (5%), and equal to or greater than 20mm in 197 (4%) of women. In 174 (4%) of women, the endometrial thickness was not visualized on transvaginal ultrasonography. For women where the endometrial thickness was not adequately visualized, the final histology included benign endometrium (124), endometrial cancer (26), endometrial polyps (11), endometritis (7), and other pathology (7). The odds of endometrial cancer in women where the endometrial thickness was not visualized were found to be significantly higher than the odds of cancer for women with an endometrial thickness of 5-9.9 mm (OR = 5.23, 95%CI 3.10-8.85, p-value <0.0001). For women presenting with postmenopausal bleeding and where the endometrial thickness cannot be adequately visualized on ultrasonography, hysteroscopic evaluation is recommended.

Antibiotic prophylaxis in diagnostic hysteroscopy: is it necessary or not?

Surgical site infection remains the most common complication of surgery. Up to 5% of patients undergoing operative procedures will develop an infection leading to a prolonged hospital stay with increased cost. On the other hand the indiscriminate use of antibiotics has been associated with the development of antibiotic-resistant bacteria. The aim of this study was to examine the effect of antibiotic prophylaxis in cases of diagnostic hysteroscopy. This was an eight-year randomized controlled clinical trial. The study group consisted of 364 women who underwent diagnostic hysteroscopy because of menometrorrhagia, post-menopausal vaginal bleeding, ultrasound findings of increased thickness of the endometrium, or as a routine examination prior to a first in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Of the 364 women who underwent diagnostic hysteroscopy during this eight-year study period, 176 received antibiotic prophylaxis whereas 188 did not. There were no significant differences in the prevalence of postoperative infections observed between women who received antibiotic prophylaxis (0.57%) and those who underwent the procedure without prophylaxis (0.53%). Given the very low risk of infection after diagnostic hysteroscopy and lack of evidence of efficacy, routine antibiotic prophylaxis is not recommended.

Locally Recurrent Endometrial Cancer: A Case Report

Endometrial cancer is the most common malignancy of the female genital tract. It is typically a disease of postmenopausal women and often presents with postmenopausal vaginal bleeding. In 75% of cases, it is diagnosed at an early stage and is associated with better overall survival rates than many malignancies. The appropriate staging surgery for patients diagnosed with endometrial cancer is a total hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymphadenectomy. Adjuvant radiation therapy in early-stage disease is associated with decreased rates of locoregional recurrences but does not improve overall survival. The role of chemotherapy is not well established for early-stage disease. Treatment recommendations for locoregional recurrence of endometrial cancer after hysterectomy are poorly defined and include tumor-directed radiation therapy, and/or chemotherapy, and/or surgical resection. Because the current guidelines are not specific, they are confusing to clinicians. To illustrate this, this report presents a patient who was diagnosed with stage IA endometrial cancer and developed vaginal cuff recurrence 3 months after surgery.

Postmenopausal vaginal bleeding in women using hormone replacement therapy

To estimate the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding using estrogen-progestogen hormone replacement therapy (HRT) regimens and to assess if the duration of HRT use has an effect on the risk of diagnosing endometrial cancer. Cross-sectional study of consecutive women presenting with postmenopausal vaginal bleeding at a gynaecological oncology centre in the UK. Main outcome measures Endometrial cancer diagnosis. Over a 62-month period, 4847 women were investigated for postmenopausal vaginal bleeding. The majority of women (4097, 84.5%) did not use any HRT preparation at the time of initial referral and 750 (15.5%) women were using combined HRT preparations. A total of 298 (6.1%) women were diagnosed with endometrial carcinoma. Women using HRT preparations were significantly less likely to be diagnosed with endometrial cancer compared with women not using HRT (adjusted odds ratio = 0.229, 95% CI 0.116-0.452; P < 0.0001). The longer duration of HRT use did increase the risk of diagnosing endometrial cancer in women presenting with postmenopausal vaginal bleeding, but this was not statistically significant. Postmenopausal women presenting with vaginal bleeding and using combined HRT preparations have significantly lower risk of being diagnosed with endometrial cancer when compared with women not using HRT.

Outcome of investigations for postmenopausal vaginal bleeding in women under the age of 50 years

ObjectiveThe objective of this study is to determine the incidence of endometrial cancer in young postmenopausal women presenting with vaginal bleeding. MethodsCross-sectional study of postmenopausal women presenting with vaginal bleeding in a gynaecological oncology centre in the United Kingdom. All women underwent transvaginal ultrasound scanning (TVS) as the initial investigation tool to evaluate the endometrium. Endometrial biopsy was performed only in cases where endometrial thickness measured equal to or greater than 5mm. The patients were divided into two groups based on their age: less than 50years (Group A) and 50years or older (Group B). ResultsOver a 57-month period, 4454 women were investigated for postmenopausal vaginal bleeding. Of these, 259 (5.8%) women were diagnosed with endometrial carcinoma. 260 (5.8%) women were younger than 50years. Endometrial biopsy was not performed in 130 women in Group A that had an endometrial thickness measurement of less than 5mm on ultrasonography. With a median follow-up period of 3 (1–5) years, we found no cases of endometrial cancer in women under the age of 50 that did not undergo endometrial biopsy at the time of initial evaluation. Overall, no cases of endometrial cancer were diagnosed in postmenopausal women under the age of 50years. ConclusionsWe found no cases of endometrial cancer amongst 260 women presenting with postmenopausal vaginal bleeding under the age of 50years. These women could be investigated on a less urgent basis depending on the available resources.

Mullerian Adenosarcoma of Uterus with Sarcomatous Overgrowth and Heterologous Component Associated with Stromal Deposit in Omentum: A Case Report and Review of the Literature

Background. Mullerian adenosarcoma with sarcomatous overgrowth (MASO) is a very rare variant of uterine sarcomas first described by Clement et al. as early as 1974. The presence of heterologous sarcomatous components is associated with aggressive biological behavior. Case Presentation. This is a case report of a 62-year female (P2 + 0) presenting with postmenopausal vaginal bleeding. Her preoperative USG revealed subserosal fibroid with adherent omentum. She underwent abdominal hysterectomy with bilateral oophorectomy. Histopathological diagnosis of resected specimen was Mullerian adenosarcoma with sarcomatous overgrowth and presence of heterologous elements involving body of the uterus. The whole thickness of the myometrium was involved along with the presence of serosal nodules and omental deposits of sarcomatous component. Conclusion. MA is considered as a low-grade malignant tumor, but MASO is a high-grade tumor frequently associated with invasion and metastasis with poor treatment outcome. Because of its rarity, correct identification of these tumors and distinction from other uterine sarcomas are a challenging job and hence its morphological features merits attention.

Coexisting Malignant Melanoma and Blue Nevus of the Uterine Cervix: An Unusual Combination

Malignant melanoma (MM) and blue nevi of the uterine cervix are an extremely rare neoplasm, probably derived from embryologic migration of melanocytes from the neural crest. MM displays aggressive behavior with a poor prognosis. We report the case of a 76-year-old postmenopausal woman abnormal vaginal bleeding. She underwent a hysterectomy and bilateral salpingo-oophorectomy with paraaortic-iliac lymphadenectomy. Histopathological and immunohistochemical studies were consistent with the diagnosis of MM and blue nevi in the uterine cervix. Although it is extremely rare, this case suggests that MM of the uterine cervix should be considered in the differential diagnosis of undifferentiated neoplasm. Early diagnosis is essential in order to warrant a better prognosis, although there are no cases of cure described.

A new technique to biopsy both horns in a septate or bicornuate uterus

References Cayuela E, Perez-Medina T, Vilanova J, et al. 2009. True osseous metaplasia of the endometrium: the bone is not from a fetus. Fertility and Sterility 91:1293.e1 – e4. Graham O, Cheng LC, Parsons JH. 2000. Th e ultrasound diagnosis of retained fetal bones in West African patients complaining of infertility. British Journal of Obstetrics and Gynaecology 107:122 – 124. Jegede AS, Fayemiwo AS. 2010. Cultural and ethical challenges of assisted reproductive technologies in the management of infertility among the Yoruba of Southwestern Nigeria. African Journal of Reproductive Health 14:115 – 127. Sahinoglu Z, Kuyumcuoglu U. 2003. An unusual case of postmenopausal vaginal bleeding: retention of fetal bone. Archives of Gynecology and Obstetrics 2:160 – 162.

Laparoscopic Retrieval of Migrated IUD for a Patient with Stage Ib2 Cervical Cancer: Case Report

To report a successfully laparoscopic retrieval of a translocated IUD for a patient with cervical cancer. Case report. University hospital Patient with cervical cancer. A 54-year-old woman (gravida 6, para 6) was referred to our department in January 2011 because of post-menopausal vaginal bleeding and abdominal pain. Pelvic examination revealed a large cervical lesion over 5 cm in greatest diameter, and biopsy analysis confirmed the moderately to poorly differentiated squamous cell cervical carcinoma. She was referred to radiation therapy as her diagnosis was FIGO stage Ib2 and she preferred radiation therapy. Pelvic magnetic resonance imaging failed because she was found to have metals in her body. A plain abdominal X-ray revealed an IUD in her pelvis. Furthermore, the IUD was found to be translocated. The migrated IUD was confirmed during CT scan which was found to be located between the tumor and rectum. An ultrasound showed an empty uterine cavity. She started her external beam radiation in January 2011. Two weeks from her initial radiation, the radiologist referred her to our clinic for the removal of IUD. Informed consent was signed. She was placed in the dorsal lithotomy position, general anesthesia was used. During laparoscopic examination, the uterus appeared normal. The IUD was located near the lower uterine segment. Half of the IUD was easily visualized, half of it submerged under the peritoneal layer, embedded in the uterine wall. The IUD was grasped; the loop was cut into two strings, and removed separately. Hemostasis was achieved by careful cautery of the peritoneal edges. The patient was discharged on postoperative day four uneventfully, and continued her radiotherapy. Translocated IUD retrieval prior to radiotherapy for patient with cervical cancer should be considered. Laparoscopy is a useful tool for the management of translocated IUD.

Estimating the Risk of Endometrial Cancer in Symptomatic Postmenopausal Women: A Novel Clinical Prediction Model Based on Patients' Characteristics

The aim of this study was to develop a multivariable model to predict the risk of endometrial carcinoma in postmenopausal women with vaginal bleeding using individuals' clinical characteristics. This prospective study of consecutive postmenopausal women presenting with vaginal bleeding was conducted at a gynecological oncology center in the United Kingdom for a 46-month period. All women underwent transvaginal ultrasound scanning as the initial investigation tool to evaluate the endometrium. Women found to have an endometrial thickness 5 mm or more had endometrial sampling performed. Of a total of 3548 women presenting with vaginal bleeding during the study period, 201 (6%) women had a diagnosis of endometrial carcinoma. An investigator-led best model selection approach used to select the best predictors of cancer in the multiple logistic regression model showed that patient's age (odds ratio [OR], 1.06), body mass index (OR, 1.07), recurrent episodes of bleeding (OR, 3.64), and a history of diabetes (OR, 1.48) increased the risk of endometrial malignancy when corrected for other characteristics. The mentioned clinical variables satisfied the criteria for inclusion in our predictive model called FAD 31 (F for the frequency of bleeding episodes, A for the age of the patient, D for diabetes, and the number 31 represents the BMI cut-off value). The total score for the model varies from 0 to 8. The area under the receiver operating characteristics curve for the developed model was 0.73 (95% confidence interval, 0.70-0.77). We have developed a simple model based on patients' clinical characteristics in estimating the risk of endometrial cancer for postmenopausal women presenting with vaginal bleeding. The model shows reasonable discriminatory ability for women with cancer and without, with an area under the receiver operating characteristics curve of 0.73. This will allow clinicians to individualize the diagnostic pathway for women with postmenopausal vaginal bleeding.

Diagnostic performance of urgent referrals for suspected gynaecological malignancies

The objective of this study was to investigate the outcome of the urgent referrals with suspected gynaecological malignancy. Retrospective analysis of the data of the urgent referrals for suspected gynaecological cancers over a 12-month period at a gynaecological oncology cancer centre in the UK. A total of 233 patients (70.61%) were referred with suspected endometrial pathology, 59 patients (17.88%) with suspected ovarian, 25 patients (7.58%) with suspected cervical and 13 patients (3.94%) with suspected vulval malignancy. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulval malignancy was 11.6, 23.7, 12.0 and 15.4%, respectively. Amongst the indications for referral for suspected endometrial cancer, presence of postmenopausal vaginal bleeding had the higher odds for cancer (odds = 0.13; 95% CI 0.08-0.21). The odds for cancer for women referred with a pelvic mass was 0.17 (95% CI, 0.07-0.42) and for women referred with abdominal bloating was 0.66 (95% CI, 0.18-2.36). All the cases of malignancy were diagnosed in women referred with suspicious appearance of the cervix on clinical examination. The odds for cancer was 0.50 if the indication for referral was vulval itching. The majority of cases of gynaecological cancers during the study period were diagnosed following routine referrals. The overall predictive value of two-week wait referrals for suspected gynaecological malignancies is low. Refinement of the current referral guidelines is required with particular emphasis in the premenopausal women where the diagnostic performance of the urgent referrals is significantly poorer.

Analyzing on the results of diagnostic curettage with postmenopausal and menopausal irregular vaginal bleeding and the nursing strategy

Objective To explore the etiologic characters of patients with postmenopausal and menopausal irregular vaginal bleeding and point out the nursing strategy. Methods A total of 6868 outpatient/ward cases with postmenopausal and menopausal irregular vaginal bleeding in our hospital from June 1999 to June 2009 were collected and retrospective analysis was made on the clinical data. Results Among the 6868 cases, 4702 (68.46%) were with functional uterine bleeding, 1322 (19.3% ) with inflammation, 404(5.9%) with atypical hyperplasia, 220 (3.2%) with cancer and 220 (3.2%) with complex hyperplasia. As the age increased, the incidences of complex hyperplasia and caner increased and those of functional uterine bleeding, inflammation, and atypical hyperplasia decreased. The results showed that the older the age of patients with functional uterine bleeding, the higher the incidences of the cancer, and the highest occurred in 65 ～74 groups (59.1% ). Conclusions The patients with postmenopausal irregular vaginal bleeding or menopausal irregular vaginal bleeding should consult doctors and be examined in time. Diagnostic curettage and pathological examination are necessary for early discovery and treatment. This will be benefit to healthcare of mid- and old-aged women. Key words: Postmenopausal irregular vaginal bleeding; Menopausal irregular vaginal bleeding; Diagnostic curettage; Nursing

Post-menopausal vaginal bleeding caused by carcinoma of the appendix: a case report

IntroductionPost-menopausal blood loss is a common complaint of patients seen in gynecological practice. The most frequent malignancy found in cases of post-menopausal bleeding is endometrial cancer. Other causes can be malignancies of the rest of a woman's genital tract or metastases from other tumors. To the best of our knowledge, it appears that this is the first published case of a post-menopausal primary appendiceal carcinoma presenting with vaginal blood loss.Case presentationA 75-year-old Caucasian woman with a history of vaginal hysterectomy presented with a 10-month history of post-menopausal blood loss. After extensive examination and discussion, ovarian carcinoma was suggested. Microscopic examination of the tissue removed at laparotomy revealed an adenocarcinoma of the appendix. She was treated with adjuvant radiotherapy and with palliative chemotherapy after 14 months because of intra-abdominal metastatic disease.ConclusionPost-menopausal blood loss in a patient with a history of hysterectomy is uncommon and always needs further investigation.

Predicting the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding: the Norwich DEFAB risk assessment tool

Background:This study aimed to show the longitudinal use of routinely collected clinical data from history and ultrasound evaluation of the endometrium in developing an algorithm to predict the risk of endometrial carcinoma for postmenopausal women presenting with vaginal bleeding.Methods:This prospective study collected data from 3047 women presenting with postmenopausal bleeding. Data regarding the presence of risk factors for endometrial cancer was collected and univariate and multivariate analyses were performed.Results:Age distribution ranged from 35 to 97 years with a median of 59 years. A total of 149 women (5% of total) were diagnosed with endometrial carcinoma. Women in the endometrial cancer group were significantly more likely to be older, have higher BMI, recurrent episodes of bleeding, diabetes, hypertension, or a previous history of breast cancer. An investigator best model selection approach was used to select the best predictors of cancer, and using logistic regression analysis we created a model, ‘Norwich DEFAB’, which is a clinical prediction rule for endometrial cancer. The calculated Norwich DEFAB score can vary from a value of 0 to 9. A Norwich DEFAB value equal to or greater than 3 has a positive predictive value (PPV) of 7.78% and negative predictive value (NPV) of 98.2%, whereas a score equal to or greater than 5 has a PPV of 11.9% and NPV of 97.8%.Conclusion:The combination of clinical information with our investigation tool for women with postmenopausal vaginal bleeding allows the clinician to calculate a predicted risk of endometrial malignancy and prioritise subsequent clinical investigations.